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Why Correctional Medicine is often Driven by Lawsuits

Imagine, if you will, a nurse who is assigned to take care
of 50 patients on a medical floor—by herself. Clearly, this is an impossible
task. There are just too many patients
for one nurse to adequately monitor. But
this nurse gamely does her best. Now let’s
say that there is a bad outcome and an investigation. Even if the understaffing problem is
recognized, it would be easy—and tempting–to scapegoat the nurse, especially
if there was no intention of fixing the staffing problem (“We can’t afford to
hire more nurses!”) Instead, the
scapegoated nurse would be replaced by a new nurse, who, once again, would be
expected to care for 50 patients.

Such were my thoughts when I read this article about the
problems with the medical care for inmates in the Illinois prison system (found
here): https://www.chicagotribune.com/news/local/breaking/ct-met-illinois-prison-health-lawsuit-20190103-story.html.
The article says that there have been so many problems with medical care in the
Illinois prison system that a class action lawsuit has successfully forced Illinois
to make sweeping changes to the prison medical system. What is not mentioned in the article is that
similar lawsuits have happened before in other states and will happen
again.

It starts here: the
main factor that results in poor medical care in prison systems in the United
States is that they tend to be severely underfunded. Because they are underfunded, prison medical
systems are almost universally understaffed, especially with nurses, but also
with medical practitioners. Medical
personnel do their best, but if you are working in a prison and are trying to
shoulder the workload of two or three FTEs, well, it might not always turn out
well.

So how did prisons end up in this situation?

Funding and staffing for medical care have not
kept pace with the huge increases in the sheer number of incarcerated inmates
that began in the 1970s. This is also
true of other parts of the prison systems, such as housing. Many state prison systems are severely
overcrowded.

The prison inmate population is getting older
and sicker. Older and sicker patients
will, of course, need more medical care than a young and healthy cohort. Funding
for medical care in prisons has not kept pace with the aging of American prison
inmates.

Nursing wages have risen steeply in the last
several years. Prisons are competing
with hospitals, outside clinics and everyone else for nurses. In general, prisons do not pay enough to be
truly competitive. Prisons are hard
paces to work and so should pay commensurately higher wages than, say, a
hospital. But this is not the case in
most prison systems. As a result, it is
not unusual for a typical state prison system to have, say, one third of its
nursing positions vacant.

Medical care in the United States is getting
more and more expensive and prison budgets have not kept pace. Examples are plentiful but here is a good
one: Treatment for Hepatitis C is now
highly effective but also very expensive.
The prevalence of Hepatitis C in prison inmates averages around
18%. To treat every one of them with a
treatment that costs many, many thousands of dollars apiece—well you do the
math for your state. It is a lot.

So why has funding for prison medical systems not kept pace
with the needs of the incarcerated inmates?

Because such funding has to be approved by each state’s
legislature. And this is often a hard
sell. Legislators may ask “Why are we
spending millions more on inmate health care when many of my not-incarcerated
constituents cannot get health insurance?”
This is a reasonable question.
Plus, free constituents vote!
Inmates do not. A legislator who
introduces a bill to, say, fund millions for Hepatitis C treatment for prison inmates
may not be a legislator for long! Inmate
medical care is a political “poison pill.”

This is why increases for prison healthcare funding often
are driven by lawsuits. Since the
Supreme Court has ruled that inmates have a constitutional right to necessary
medical care (Estelle v. Gamble, 1976), a lawsuit that shows that inmates are
not receiving adequate medical care will usually win. And this opens the door for legislators to
write the check for increased prison medical funding without having to pay a
political price. “I had to vote for this
even though I didn’t want to.” they can say to constituents. This has happened
many times in other states before Illinois and will continue to happen in the
future.

In nutshell, then, this is our dysfunctional relationship with
prison medical care in the United States:

As inmate population rises and inmates get older, funding for their medical care becomes inadequate. This results (among other things) in understaffed medical services. Legislatures won’t increase medical funding because that would be politically untenable. With time, underfunding and understaffing lead to bad medical outcomes. Advocacy attorneys then file class action lawsuits on behalf of inmates alleging inadequate medical care—and win. This forces the legislature to increase funding for medical care, which they can now do without paying a political price. And then the cycle repeats itself. This cycle is being played out over time in most US states, including, probably, yours. So don’t be surprised by the next, inevitable, news article about a successful lawsuit forcing a state to increase funding for prison inmate medical care, because that is how the system works.

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6 thoughts on “Why Correctional Medicine is often Driven by Lawsuits”

Excellent article. It addresses the point directly. I agree that when it’s all said & done, the ultimate result of lawsuits has been an improvement in the patients’ care. It’s unfortunate that it has to be that way; but that’s the way it is. I suggest we forward this article to our state & federal legislatures. Very good Jeff, as usual.

I was reading about the Hep C treatment mandates. In Michigan their entire prison pharmacy budget was somewhere around $27 million dollars and after it was mandated they had to treat all Hep C patients with the drugs their budget rose to $110 million dollars. I want to provide care but these judgments whether warranted or not will simply place burdens on the system and I fear will push everyone to find cost saving in other areas that may hurt overall care of the incarcerated. What will we do if a cure for HIV comes out and it costs $1 million per person are we going to treat everyone as well? I want to take care of my patients but it does seem unfair that someone in prison is entitled to very expensive medical care that people outside the system may not be able to afford or qualify for and that can be frustrating as well.

It’s not an issue of “unfairness”. Is it “fair” that some live in wealth while others live in poverty? Society decided to incarcerate those found guilty of a crime. Therefore, society now has the responsibility of providing for them. That is why. I bet those incarcerated would rather be free without Hep C treatment than be incarcerated with treatment. Now that society has made those choices they now have to pay.

Unfortunately it is not the Legislators nor Society that are dragged into court to defend the lack of resources in the care of inmates. It is often the health staff who are the ones most often sued and who have limited control over budgets!
RH Rowe MD

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Jeffrey Keller

About

Jeffrey E. Keller is a Board Certified Emergency Physician with 25 years of emergency medicine practice experience before moving full time into his “true calling” of Correctional Medicine. He is the Medical Director of Badger Medical, which provides medical services to several jails and juvenile facilities in Idaho. Dr. Keller is available for consultation on any aspect of Correctional Medicine, including legal cases, program development, and system analysis.

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